ABSTRACT
BACKGROUND: Prior to the availability of generic third-generation cephalosporins, penicillins were widely used for treatment of pneumococcal meningitis in developing countries despite concerns about rising levels of penicillin resistance among pneumococcal isolates. We examined the impact of penicillin resistance on outcomes of pneumococcal meningitis over a ten year period in an infectious diseases hospital in Brazil. METHODS: Clinical presentation, antimicrobial therapy and outcomes were reviewed for 548 patients with culture-confirmed pneumococcal meningitis from December, 1995, to November, 2005. Pneumococcal isolates from meningitis patients were defined as penicillin-resistant if Minimum Inhibitory Concentrations for penicillin were greater than 0.06 µg/ml. Proportional hazards regression was used to identify risk factors for fatal outcomes. RESULTS: During the ten-year period, ceftriaxone replaced ampicillin as first-line therapy for suspected bacterial meningitis. In hospital case-fatality for pneumococcal meningitis was 37%. Of 548 pneumococcal isolates from meningitis cases, 92 (17%) were resistant to penicillin. After controlling for age and severity of disease at admission, penicillin resistance was associated with higher case-fatality (Hazard Ratio [HR], 1.62; 95% Confidence Interval [CI], 1.08-2.43). Penicillin-resistance remained associated with higher case-fatality when initial therapy included ceftriaxone (HR, 1.68; 95% CI 1.02-2.76). CONCLUSIONS: Findings support the use of third generation cephalosporin antibiotics for treatment of suspected pneumococcal meningitis even at low prevalence of pneumococcal resistance to penicillins.
Subject(s)
Anti-Bacterial Agents/administration & dosage , Meningitis, Pneumococcal/drug therapy , Meningitis, Pneumococcal/microbiology , Penicillin Resistance , Streptococcus pneumoniae/drug effects , beta-Lactams/administration & dosage , Adolescent , Adult , Aged , Aged, 80 and over , Brazil , Child , Child, Preschool , Female , Hospitals , Humans , Infant , Infant, Newborn , Male , Meningitis, Pneumococcal/mortality , Microbial Sensitivity Tests , Middle Aged , Treatment Outcome , Young AdultABSTRACT
BACKGROUND: Inhabitants of slum settlements represent a significant proportion of the population at risk for pneumococcal disease in developing countries. METHODS: We conducted a household survey of pneumococcal carriage among residents of a slum community in the city of Salvador, Brazil. RESULTS: Among 262 subjects, 95 (36%) were colonized with Streptococcus pneumoniae. Children <5 years of age (OR, 8.0; 95% CI, 3.5-18.6) and those who attended schools (OR, 2.7, 95% CI, 1.2-6.0) had significantly higher risk of being colonized. Of 94 isolates obtained from colonized individuals, 51% had serotypes included in the seven-valent pneumococcal conjugate vaccine. Overall, 10% (9 of 94 isolates) were nonsusceptible to penicillin and 28% (27 of 94 isolates) were resistant to cotrimoxazole. BOX-PCR, PFGE and MLST analyses found that 44% of the carriage isolates belonged to 14 distinct clonal groups. Strains of the same clonal group were isolated from multiple members of 9 out of the 39 study households. Nineteen carriage isolates had genotypes that were the same as those identified among 362 strains obtained from active surveillance for meningitis. CONCLUSIONS: The study's findings indicate that there is significant intra- and inter-household spread of S. pneumoniae in the slum community setting. However, a limited number of clones encountered during carriage among slum residents were found to cause invasive disease.
Subject(s)
Carrier State/epidemiology , Carrier State/transmission , Streptococcus pneumoniae/classification , Streptococcus pneumoniae/isolation & purification , Adolescent , Adult , Age Factors , Anti-Bacterial Agents/pharmacology , Bacterial Typing Techniques , Brazil/epidemiology , Carrier State/microbiology , Child , Child, Preschool , Cluster Analysis , DNA Fingerprinting , DNA, Bacterial/genetics , Drug Resistance, Bacterial , Female , Genotype , Heptavalent Pneumococcal Conjugate Vaccine , Humans , Infant , Male , Meningococcal Vaccines/immunology , Microbial Sensitivity Tests , Pneumococcal Vaccines/immunology , Poverty Areas , Risk Factors , Schools , SerotypingABSTRACT
The long-term impact of Haemophilus influenzae type b (Hib) conjugate vaccine, introduced throughout Latin America in the late 1990s, has not been evaluated. Active surveillance for H. influenzae meningitis was performed from August 9, 1996 to August 8, 2004 in Metropolitan Salvador, Brazil. Five years after the introduction of Hib conjugate vaccine, Hib meningitis incidence decreased from 2.39 to 0.06 cases per 100,000 population (98%) overall, and from 60.9 to 3.1 cases per 100,000 population (95%) in children <1 year of age. A transient serotype replacement phenomenon was observed associated with a small increase of meningitis due to two H. influenzae type a clonal groups. These findings indicate that Hib immunization campaign has led to the virtual elimination of Hib disease in this region.
